Destination:
Dhaka, Bangladesh
Cleft Lip and Palate
Team
This is our second
trip to the Jibon
Tari Floating
Hospital
Team Registration is
a Three Step Process
2)download
the forms
which need
updating in
your personnel file
as indicated on
chart below (click
on the next link)
~~DOWNLOAD
MEMBERSHIP FORMS
HERE~~
This is to be
completed and mailed
or faxed to the
HTCNE office
(860) 350 6634 - fax
3)
IF the chart below shows
that a
CV, Diploma, Medical
license, or
Delineation of
Privileges is needed,
please fax or email
them to the office right
away. We need
these to secure your
working permits in
country. See
above for fax
number.
Destination:
Dhaka,
Bangladesh
Specialty:
OMS /
Plastic
Surgery
Team Leader:
Dr. Shahid
Aziz |
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Dates:
May 19 -
June 2, 2007 |
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Sponsor:
Impact
Foundation
Bangladesh
/
Christina |
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Updates: |
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Site Contact
Info.:
Floating
Hospital -
Jibon Tari
Office
in Dhaka:
House 13,
Road 1,
Block 1, Banani
Local
Contact:
Christina Rozario at
Impact
Foundation
Bangladesh
phone:
9893267 /
8853519 /
8815755
Apt. D1,
House 19,
Road 4,
Gulshan1,
Dhaka 1212,
Bangladesh
Team
can be
contacted at
the Royal
Park Hotel,
Dhaka:
880-2-8815945
/ 46
US
Embassy
Contact:
TBD
from
the US call
011-880-2-885-5500
ext. 2110
Hotel Info:
The
Team will be
staying
on the Boat
during
Surgery.
While in
Dhaka, at
the Royal
Park Hotel
Visa
Requirements:
See Links
Below
Flight
Information:
below
|
Click on any
Team member
name in blue
to send an
e-mail |
|
Administrative
Contact:
Jean
Hatcherson /
email: hatcherson@aol.com
203-778-4387 |
Email entire
team |
|
Participants: |
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|
Surgery |
Curriculum
Vitae |
License
to
Practice
Med.
|
Clinical
Specialty |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
2007
Dues |
Airfare |
Visa |
|
Shahid
Aziz,
OMS
Team Leader |
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
yes |
|
Jason Hullett, OMS |
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
yes |
|
Lisa
Jacob,
Plastics(RES) |
in |
NA |
in |
in |
in |
in |
in |
paid |
Paid |
? |
|
Sam
Rhee, Plastics |
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
? |
|
Llisenia Rivera, OMS |
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
? |
|
Amy Tanchyk, Dental Student |
in |
NA |
in |
in |
in |
in |
in |
paid |
paid |
? |
|
John Wallace, MD |
in |
in |
in |
in |
in |
in |
in |
cc |
paid
|
yes |
|
Pediatrics |
Curriculum
Vitae |
License
to
Practice
Med.
|
Clinical
Specialty |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
2007
Dues |
Airfare |
Visa |
|
**Impact
Foundation
will
supply
Peds.
|
n/a
|
n/a
|
n/a
|
n/a
|
n/a
|
n/a
|
n/a
|
n/a
|
n/a
|
n/a
|
|
Anesthesiology |
Curriculum
Vitae |
License
to
Practice
Med.
|
Clinical
Specialty |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
2007
Dues |
Airfare |
Visa |
|
Imre
Redai, MD
|
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
? |
|
Leydamara Carvajal |
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
? |
|
Matthew Doane |
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
? |
|
Jesse
Raiten, MD (RES) |
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
? |
|
Sukhjeewan
(Cindy)
Basran, MD (RES) |
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
yes |
|
Nursing/OR Techs/Other |
Curriculum
Vitae |
License
to
Practice
Med.
|
Clinical
Specialty |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
2007
Dues |
Airfare |
Visa |
|
Frances
Devonshire,
RN
|
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
current |
|
Lynn
Speer,
RN
|
in |
in |
in |
in |
in |
in |
in |
paid |
Paid |
? |
|
Bruce Byers, Photographer |
NA |
NA |
NA |
in |
in |
in |
need |
paid |
need |
yes |
|
|
|
|
|
|
|
|
|
|
|
|
|
Administrator |
Curriculum
Vitae |
License
to
Practice
Med.
|
Clinical
Specialty |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
2007
Dues |
Airfare |
Visa |
|
Jean Hatcherson |
NA |
NA |
NA |
in |
in |
in |
in |
cc |
part cc |
|
|
|
|
|
For general
information about
Bangladesh: Embassy
Web Site
Visa
Information: Download
Visa Application and
Instructions
Airfare
Arrangements: Ann
St.Hilare, ProTravel
1-800-227-1059 ext
274
anns@protravelinc.com
Itineraries:
May 19 - June
2: Imre Redai;
Frances Devonshire;
Lynn Speer; Shahid
Aziz:
EK 204 19May
JFK
DXB 11:20a /
8:10a
EK 584
20May
DXB
DAC 1:15p
/ 7:55p
EK585 02Jun
DAC DXB 9:30p
/
12:25a
EK 203
03Jun
DXB JFK
2:00a /
7:50a
May 19 - May
26: Llisenia Rivera;
Jesse Raitan;
Leydamara Carvajal;
Jason Hullet;
John Wallace, Jean
Hatcherson;
EK 204 19May
JFK
DXB 11:20a /
8:10a
EK 584
20May
DXB
DAC 1:15p
/ 7:55p
EK 585
26May DAC
DXB 9:30p /
12:25a
EK 203 27May DXB
JFK 2:00a /
7:50a
May 19 - June
11: Byers
EK 204 19May
JFK
DXB 11:20a /
8:10a
EK 584
20May
DXB
DAC 1:15p
/ 7:55p
EK549 10Jun Calcutta DXB
8:30p
/
11 Jun 12:05a
EK 203
11Jun DXB JFK
2:00a /
7:50a
May 26 - June
2: Samuel Rhee;
Lisa Jacob; Matthew
Doane; Amy Tanchyk
EK 204
26May JFK
DXB 11:20a /
8:10a
EK 584 27May
DXB DAC
1:15p / 7:55p
EK 585 02Jun DAC
DXB 9:30p /
12:25a
EK 203 03Jun
DXB JFK
2:00a /
7:50a
Sukhjeewan Basran:
EK 625L
26May J
LHE DXB
9:00a / 11:10a
EK 584L
26May J
DXB DAC
1:15p / 7:55p
Dhaka to Kathmandu:
GMG
21
03Jun DAC
KTM 10:30A /
11:30A
Wallace:
18 May Flt 806
Depart 6:05p DFW Arr
1:50 p JFK overnight
at the Fairfield Inn
at the airport
Fax Forms to HTC
at 860-350-6634
Mail Forms to HTC at
P.O. Box 129, New
Milford, CT 06776
E-mail to
mlaw@htcne.org |
